Provider Demographics
NPI:1568111458
Name:SHAH, VIVEK V
Entity Type:Individual
Prefix:
First Name:VIVEK
Middle Name:V
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 VANDERBILT ST
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-6928
Mailing Address - Country:US
Mailing Address - Phone:626-629-6283
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:424-306-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-20
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program